The Role of Immigrants in Providing Care to the Aging

Discussions on immigration (both legal and otherwise) are frequently emotionally charged – in part based on the perspectives and the experiences of those on either side of the debate.

Yet, all too often many of the roles of immigrants are in the background and simply go unnoticed. Some of these roles are strongly connected to care and support for the elderly, which makes them especially important.

So, it really is important to think about the role of immigrants in senior care – and what would happen if they weren’t performing that role. Immigrants do play a large role in this field, much more so than many people realize.

If you’ve ever needed to hire a home caregiver or any form of in-home help, you may already know that much of the available caregiver pool consists of foreign-born immigrant women. Many of these are grossly underpaid and overworked, and even with this workforce, there are far too few workers to meet the growing need.

Few Americans realize that the aggressive rhetoric and strict policies around immigration and immigrants may have long-term impacts that can shrink this critical workforce.

That begs the question, who will care for Americans aging population, especially as many people want to make it harder for immigrants to enter and work in the U.S.?

Why Senior Care Matters

This field is a very critical one. The American population is rapidly aging – a pattern that is also being observed across many other nations.

This is happening because the baby boomer generation is now reaching their senior years. The fertility rate has also decreased and technology is helping to extend life length and comfort into older age.

According to the 2010 Census, the group of 65 years and older has now become the largest and fastest-growing portion of the population.

• There were more than 40 million people in the U.S. at least 65 years of age in 2010. This represents 13% of the population.
• By 2016, this group totaled 49.2 million, around 15.2% of the population.
• At the same time, projections indicate that this group will continue to grow, with an estimated size of 83.7 million by 2050.

Some cities and states are seeing particularly strong growth. For example, in Miami more than 16.5% of the population are above 65 years of age.

Furthermore, as the American population ages, increasing pressure is being placed on social current systems and there is a growing need to find effective long-term care solutions for the aging.

While there are many approaches at hand to help deal with this aging population and provide for their needs – the current tools and systems were never designed for this number of seniors. To effectively cater for this aging population, both now and in the future, it is critical that we consider all potential sources of care and work to maximize these.

Additionally, more than 75% of seniors want to age in their own homes – rather than in healthcare facilities. To achieve this, many more direct care workers will be needed, especially as the population continues to grow.

Direct Care Workers

Direct care workers are the primary source of paid hands-on long-term care within the U.S., providing between 70% and 80% of this care at home, or in other settings. Most definitions consider direct care workers to fall into one of three individual job types.

• Home Health Aides
• Nursing Aides/Nursing Assistants
• Personal Care Aides

Collectively, this group offers a range of support for everyday living, including providing the frontline help with meal preparation, with dressing, and with transportation. Through these supports, this group plays a key role in helping millions of senior Americans to live at home rather than in long-term health care facilities.

As of 2017, around 4.4 million individuals are working in this field. The majority of these people work in home-based and community-based jobs, rather than institutional settings.

But, estimates vary somewhat depending on data sources. Some places also include direct care workers employed by individuals, while others do not.

Because these are three distinct roles, most statistics consider them individually. Data from the Bureau of Labor Statistics shows the following patterns:

• Home Health Aides: 814,300 individuals in the field. Around 30% are involved in home health care services and around 9% in individual and family services.
• Nursing Aides/Assistants: 1,443,150 individuals in the field. Roughly 37% are employed in nursing facilities and around 18% in retirement communities and assisted living facilities. Only around 6% involved in home health care services.
• Personal Care Aides: 1,492,250 individuals in the field. Mean hourly wage of $10.92. States with the highest level of employment include Texas, New York, California and Pennsylvania.

However, the healthcare industry is already struggling to keep up with demand and faces labor shortages at many levels of the field. There are many factors to this issue, including a lack of suitable workers and challenges in retaining current workers. This pattern is especially true for low-skilled roles.

As the size of the senior population continues to grow, this issue is likely to get much worse, making the role of immigrants in senior care that much more important.

In particular, projections indicate that an additional 1.1 million direct care workers will be needed by 2018. The Bureau of Labor Statistics also indicates that the industry of Home Health Aides and Personal Care Aides is experiencing a 41% growth rate. This is much faster than the overall average of 7%.

There are also significant concerns about health care labor shortages. Likewise, we’re likely to see shortages in direct care workers, especially as demand continues to rise. By 2030, there could be a shortage of around 151,000 direct care workers and 3.8 million (unpaid) family caregivers.

Increasing immigration may be a key way to improve outcomes and ensure that seniors get the support they need.

Immigrants as Direct Care Workers

So then, what roles do immigrants actually play?

Research suggests that roughly 25% of direct care workers are immigrants. In 2015, this group totaled around 860,000 individuals. If independent providers are considered as well, there may be more than 1 million immigrants in this field.

The proportions also vary depending on location. In New York, California, Hawaii, Florida, and New Jersey immigrants comprise more than 40% of direct care workers.

Key details and demographics about this population include the following:

• Compared to other direct care workers, immigrants tend to be older. The median age is 48, while native-born workers have a median age of 38.
• There is an increased prevalence of higher education among the immigrant workforce.
• The majority of immigrant direct care workers are female (85%). This is similar to the native-born workforce, where 87% are female.
• Income for immigrants in this role is often low. Many people are only able to work either part-time or for part of the year – and the median income is just $19,000. For many families, this means relying on benefits for survival.
• Estimates suggest that around 44% are not citizens, while 56% are citizens by naturalization.
• Around 33% of immigrants have been in the United States for 25 years or more.
• The most common language for immigrant direct care workers is Spanish, with Mexico being one of the top countries of origin. Other top countries are the Philippines, Jamaica, and Haiti.

Immigrants as Direct Care Workers

Although immigrants only make up around one-third of all direct care workers, the statistics show that they have great potential to play a key role in direct care. This is likely to be increasingly important as the elderly population continues to grow and the need for direct care workers continues to increase.

Statistics for immigrants also just consider the legal workforce. There may be a higher proportion of immigrants hired by families.

Regardless, the role that immigrants are able to play in this growing healthcare crisis is strongly influenced by U.S. immigration policies.

Currently, there are three key pathways for immigrants to play a role in direct care. These are:

1. Legal permanent admission (with a visa supporting work)
2. Legal temporary admission (with a visa supporting work)
3. Unauthorized work (with either authorized or unauthorized entry)

Many direct care immigrant workers qualify through an EB-3 visa. This visa allows for ‘skilled workers’, ‘professionals’ and ‘other workers’. It is an alternative option to the EB-1 and EB-2 visas, with less stringent requirements than the EB-1 and EB-2 visas.

Even then, the EB-3 visa has a large backlog and a sponsoring employer is still needed. The number of immigrants that can be accepted each year is capped, which contributes to the backlog in obtaining this visa.

Some potential healthcare workers won’t have the skills in this field initially, which limits their options as well. They have to rely on the EB-1 and EB-2 visas, and these can be difficult to obtain.

Unauthorized Workers

Estimating the number of unauthorized immigrants and unauthorized workers in the U.S. is challenging, but one estimate suggests close to 11 million.

Another estimate suggests that around 8 million unauthorized immigrants are part of the workforce, although growth in this number is beginning to slow down.

These numbers are very rough estimates and there is no way to know for certain. Some counts are likely to underestimate the number of illegal immigrants, while others may over-estimate the population.

Regardless, unauthorized immigrants in senior care represent a significant group of people and the implications of this pattern are widespread.

In the direct care field, estimates suggest that 79% of the workers in the field are legal, with unauthorized workers making up close to 21% of the direct care workforce.

This highlights just how critical immigrants already are in the direct care workforce and underscores the significance of making it easier (not harder) for them to get involved.

Immigration Policy

Policies on immigration can have strong impacts on the ability of immigrants to enter the U.S. and work legally.

On June 27, 2013, an immigration reform bill (Senate Bill 744) was proposed by a group of eight bipartisan senators. The reform was designed to provide a pathway towards citizenship for current illegal immigrants, to develop an employment verification process and improve work visa options for low skill roles.

In concept, the bill would have boosted the economy, while also benefitting immigrants. In doing so, the bill would have had significant benefits in many aspects of American society, including in the direct care field where more workers are urgently needed.

Not surprisingly, the bill is also a controversial one – as many people in the U.S. hold strong anti-immigrant sentiments and do not support creating a pathway for immigrants to legally work if they entered the country illegally.

Hearings on the bill were held in April 2013 and it was voted out of committee in May 2013 and then introduced to the Senate where it was passed. However, it is unclear whether the House of Representatives will even consider the bill. Instead, there has been an increased focus on interior enforcement and border security, an approach that penalizes immigrants.

President Obama relied on executive actions to push through immigration reforms.

• For example, one such executive action focused on allowing some immigrants to apply for work permits or deportation reprieves. This specifically focused on individuals with children in the U.S. who are legal residents or American citizens.
• Likewise, executive action focused on expanding the Deferred Action for Childhood Arrivals program, offering more options for immigrants who entered the U.S. as children.

However, the resistance to such legislation has been considerable. This is particularly evident under Trump, who is taking a strong anti-immigration stance.

This stance is already causing ripples in the home health field, with fewer people applying for positions and others being forced out of the country. Discussions on health care reform may also have significant impacts on direct care workers, although it’s too early to know the precise implications.

While policies at the national level have largely resulted in stalemates, there has been some progress at local levels.

• For example, New York, California, Hawaii, and Massachusetts have all passed domestic worker bills that support domestic workers and offer greater levels of rights and improved labor laws.
• In 2015, Oregon became the 5th state to sign such a bill into law.

Although the bills vary from one state to another, the general approach is adding in protections and provisions for domestic workers. Some examples include overtime pay, paid personal time, as well as protection from harassment.

This practice is especially important, as historically domestic workers were excluded from fair labor laws. The domestic worker bills show that states are beginning to recognize the rights of domestic workers. These bills still do not cover everyone, but they are a good start.

These bills also help to set the stage for a federal bill that tackles the same problem.

Until that happens, it seems that the rights of domestic workers are going to vary from state to state.

Refining Immigration Law

Immigration policies are always going to be a challenging topic, especially because there are so many strong opinions about immigration. Additionally, the different views about immigration are hard to reconcile with one another. For example, many people who are strongly anti-immigration will believe that some groups of immigrants are beneficial for the nation, regardless of what evidence they are faced with.

Despite this, it is important to discuss immigration from a realistic viewpoint.

• As this discussion has shown, immigrants do play a key role in the direct care workforce, and this is also likely to be true in some other areas of the workforce.
• Yet, current policies heavily restrict immigrants and their ability to participate in the labor force.
• Despite popular rhetoric, immigrants have the potential to support the American economy, rather than draining it. For example, research shows that authorized immigrants earn more than unauthorized ones for the same work, particularly as they have access to better jobs.

Making it easier for people to legally work in the U.S. also puts immigrant workers at on an even playing field compared to native-born workers, creating fairer competition for jobs. This can actually make it easier for native-born workers to get jobs as well, as they are not competing against others who are working under the table for lower wages.

At the same time, giving immigrants the ability to earn money legally increases tax revenue and can potentially decrease crime as immigrants can rely on legal means to earn money.

Increases in income for immigrants also increases their standard of living and their ability to buy their own homes. This decreases reliance on government assistance and allows immigrants to contribute more to the economy. In turn, this can contribute to the development of more jobs.

This progression also has both direct and indirect impacts on the healthcare field.

• For one thing, making it easier for immigrants to work legally is likely to increase the number of direct care workers – especially as there are many jobs available in the field.
• Another thing is that the potential to earn more money legally means that many immigrants would end up earning more money. For many individuals this would help to lower stress and potentially workload (as they would not have to work multiple jobs), this could act to improve the quality of care.
• Having more legal workers in the direct care workforce is also important for quality control. This allows for improved training and makes it easier to ensure that all direct care workers are doing their jobs effectively.

Yet, actually making any changes to immigration law is a lot easier said than done.

In recent years, Republicans have focused on over-enforcing immigration, including using walls to prevent immigration as well as the deportation of as many illegal immigrants as possible within the United States. Such rhetoric has become increasingly common and there are many modern discussions about decreasing immigration still further.

At the same time, Democrats have struggled to push immigration reform, often being inactive or not focusing on the area.

Until this issue is addressed and addressed realistically, the nation will continue to suffer.

Focusing on immigration as a bad thing entirely overlooks the nuances of immigration and the positive role that many immigrants do play in American society.

In fact, many unauthorized immigrants follow American law in every way possible even given the restrictions that their position places on them.

Domestic Workers, Immigration, and the Aging Population

Even with the challenges and controversy surrounding immigration and immigration reform – it is clear that immigrants do play a key role in the workforce, including in direct care roles.

Currently, native-born workers in the direct care field are unable to meet the demand for direct care and that demand is only going to increase as time goes on.

Immigrant workers are a key and integral part of the healthcare system because of their role in direct care. This makes it important that a new immigration system is developed that focuses on stabilizing the direct care workforce, strengthening the American economy and helping seniors overall.